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HomeMy WebLinkAboutBLDG-22-003324 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it kzeCITY YARMOUTH MA DATE December 10,202' PERMIT# BLDG 22 003324 JOBSITE ADDRESS 51 CIRCUIT RD NORTH OWNER'S NAME Romv Miamon G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Olsen LICENSE# 10335 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: Richard P Olsen ADDRESS. PO BOX 2026, CITY DENNIS STATE MA ZIP 026385026 TEL FAX CELL EMAIL S31ON M3IA3a NVId #lii d $:33d ❑ ❑ 11VM3d 31i1 SV S3A213S NOI1VOIlddV SIHl oN saA S31ON NO1103dSNI 1VNId AINO 3Sf1 a0103dSNI HOd 30Vd SIHI S310N NO1103dSNI SVO HOl0a ' a ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ____ "I -� CITY \� \ cAi Mo MA DATE I lf�z PERMIT # 1 QMITE AD RESS !� L 1.(CU.1'�-_ cact , ,, . m OWNER'S NAME �i...,.. , � r31_11 FG DE F;PNIRERFA "M ESS _._�. TEI� �D FAX PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALQ CLEARLY NEW: RENOVATION: REPLACEMENT: ) PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER = ___ ,: DRYER FIREPLACE _. FRYOLATOR - FURNACE ' - GENERATOR =— GRILLE INFRARED HEATER LABORATORY COCKS -- MAKEUP AIR UNIT OVEN i - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST ----- � . ----,7-- UNIT HEATER -- UNVENTED ROOM HEATER WATER HEATER . _ --., ----- OTHER .._._.. _. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES i NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY ... BOND I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER i AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t best my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance-wi • all P in n �4 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER-GASFITTER NAME Richard Olsen LICENSE # M10335 SIGNATURE MP MGF JP JGF LPGI 0 CORPORATION i # 2166 PARTNERSHIP # LLC , # COMPANY NAME:rOlsen Plumbing & Heating ADDRESS P.O. Box 2026, 357 Hokum Rock Road1 _1 ! MA ZIP! 02638 TEL 508-385-5290 ..... ._, _______,...,_ _,... CITY . Dennis STATE V FAX ; 5 08-385-6963 1ICELL �S